Current Guidelines, Considerations, and Challenges of Informed Consent in Paediatric Dentistry

Paediatric Dentistry and Informed ConsentInformed consent is a dynamic process involving a discussion between healthcare provider and patient regarding a proposed treatment. The main goal of this discussion is to confirm that the patient understands the information necessary to make an informed decision regarding his or her treatment. With any dental procedure, there is an inherent degree of uncertainty with treatment outcomes, and a patient’s personal, educational, and economic factors often play an important role in treatment selection. In the practice of paediatric dentistry, these challenges are magnified by the fact that dental treatment is rarely being sought out or requested by the patients themselves, but rather by parents or legal guardians on the patient’s behalf. According to the Canadian Medical Protective Association, the only province to have legislated an age of consent for medical and dental treatment is Quebec (age 14). 1 However, the other provincial dental colleges do not specify a minimum age of consent to dental treatment, so long as the patient demonstrates that he or she is capable of understanding the information necessary to make an informed decision regarding the treatment. Therefore, paediatric dentists are faced with the challenge of ensuring that the consent they receive from the patient, parent, or a combination of both, meets the standards of care set by their respective dental college.

Informed Consent in Dentistry: What Does The Literature Tell Us?
One tenant of patient-centered care is the importance of providing information to patients for them to make informed decisions about their dental treatment.

Patients’ ability to provide informed consent is a crucial aspect of patient-centered care, and the information provided by the dentist is intended to allow the patient to take an active part in their treatment decisions. However, the vast majority of studies in the literature are focused on informed consent discussions in the context of medicine, with few studies focused on dentistry; and even fewer narrowing in on paediatric dentistry in particular.

In dentistry, studies in adult populations have demonstrated that even after an informed consent discussion has taken place, either through verbal or written consent, patients often still fail to fully understand the treatment that will be provided. It has been suggested that as high as 40% of the written consent obtained from adult patients in dentistry may not be valid, owing to significant misunderstanding or lack of understanding regarding the details of the dental procedure to be performed. 2 One study observed that amongst dental professionals of varying experience levels, attitudes towards informed consent differed significantly. 3 For example, students in third or fourth-year dental studies were among the highest to not obtain proper informed consent (36% and 21% respectively), while dental surgeons were the lowest (8.8%). 3 This may suggest a lack of duty on the part of the dental professional in taking the time to educate patients about all aspects of the dental procedure to be performed, and one particular area that could be improved upon in dental school curriculums. The same study also investigated the types of information covered in the informed consent discussion with the patient, and found that although describing the procedure was the main information covered by dental professionals during informed consent, other areas such as information about potential risks, short-and long-term effects were mentioned by less than 10% of respondents. 3 Therefore, this suggests a gap in patient understanding due in part to practitioners failing to fully disclose and explain potential risks and complications of a procedure during the informed consent process.

At present, little is known about how involving children in dental treatment discussions can affect their experience at the dentist. In one of the only studies specifically addressing paediatric dentistry and children’s perceptions and involvement in informed consent, the author’s observed that capable children expressed a desire to be involved in deciding about their dental care, and wanted to be more involved in consenting to their dental treatment. 4 The authors found that the children (aged 8 to 13 years old) felt they were involved in deciding about their dental treatment when the pre-treatment discussion involved written consent from their parents in addition to assent by the patient themselves, compared to patients whose parents were the only one who gave consent to treatment. 4 Post-treatment interviews revealed that involving children in the treatment decision lead to improved understanding of the treatment and its importance, and more importantly 75% of the children agreed that they should be involved in deciding about their dental treatment. 4 Such studies provide the dental community with valuable insight to support the notion that capable paediatric patients should be involved in informed consent discussions regarding their treatment.

While the literature is limited with regards to strategies to improve patient understanding of procedures in dentistry, research in the medical field has made positive strides in recent years. A Cochrane review investigating interventions to promote proper informed consent for patients undergoing various surgical procedures in medicine demonstrated that most interventions to improve patient understanding of procedures include enhanced written or audio-visual information, and that these interventions improve patient knowledge of the planned procedure both immediately and in the long-term. 5 Moreover, patient satisfaction with decision-making improved, and decisional conflict was reduced. 5 Among some of the factors identified in investigating patient understanding in medicine, total consent time and one-on-one interaction with the professional administering the consent have been suggested as key factors in patient comprehension. 5-8 In adults, other factors contributing to patient-reported comprehension and positive experience regarding the informed consent procedure include age, gender, education, recent dental attendance, and the patient’s own judgement regarding their health. 9

In dentistry, obtaining sufficient informed consent may minimize the potential for unpleasant outcomes such as patient non-compliance, patient dissatisfaction, and ultimately patient distrust of the dental professional. 10 In addition, failure to obtain proper informed consent has also been shown to increase the prevalence of dental malpractice claims and litigation. 11 In one study, lack of adequate information regarding procedure details was the most important problem leading to failure in the informed consent process resulting in dental malpractice claims. 11 Therefore, providing patients and their parents with comprehensive information presented in a way that maximizes their understanding of all aspects of their treatment promotes a more balanced partnership in healthcare decision-making.

Informed Consent Guidelines in Ontario
In recent years, there has been a heightened awareness amongst the dental community that informed consent is a process, and not merely a standardized document signed by the patient or their legal guardian. The onus is on the dentist to ensure that the patient and/or the legal guardian demonstrates sufficient understanding of the key aspects of treatment, according to the Royal College of Dental Surgeons of Ontario (RCDSO). According to the RCDSO, informed consent cannot be obtained if a patient fails to demonstrate understanding of the key components of the process, as outlined by Ontario’s Health Care Consent Act (HCCA)1996. 12 These key elements are outlined below:

1.Nature of the proposed treatment;2. Expected benefits of treatment;3.Material risks and side effects of treatment;4.Alternatives to proposed treatment, including no treatment, as well as the most likely consequences of declining the proposed treatment;5.Answers to any questions the patient has regarding the proposed treatment or alternatives.

In Ontario, the RCDSO guidelines for informed consent also include the proposed monetary costs of treatment, in addition to the elements listed above in the HCCA.12

How Old is “Old Enough” to Consent to Dental Treatment?
According the RCDSO guidelines, in Ontario there is no minimal age of consent when it comes to providing informed consent for dental treatment, so long as during the informed consent discussion the patient can demonstrate a thorough understanding regarding the risks, benefits, and potential consequences of forgoing treatment. 13 This begs the question: how can a paediatric dentist assess whether or not the child in his or her dental chair meets the criteria to consent to dental procedures? Or even more challenging, can the dentist proceed with treatment if the parent consents to treatment but the capable child refuses?

In order to address these questions, the RCDSO has established guidelines to help the dentist determine a patient’s capability in understanding the key aspects of their treatment decision. When considering a patient’s ability to understand the risks, benefits, and potential consequences of refusing treatment, the RCDSO states that the dentist needs to consider the chronological age, maturity level, and comprehension level of the paediatric patient. 13 In addition, the dentist also needs to consider whether the treatment being provided is elective or emergency treatment. 13
The RCDSO provides a general guideline age that can help the paediatric dentist in their early assessment when considering age of consent. The current guideline in Ontario states that while there is no set age limitation for informed consent, for children under the age of 12, informed consent should be obtained from the parent/legal guardian 13; whereas for adolescents aged 16 and above, the dentist can presume that the patient has the capacity and maturity to make his or her own decisions regarding treatment, so long as the dentist finds no evidence to the contrary. 13

For example, a 2-year-old child with advanced early childhood caries that requires extraction of the upper primary maxillary incisors is incapable of comprehending the risks associated with not rendering treatment, such as continued risk of pain, infection or cellulitis, or greater likelihood of need for unplanned emergency treatment. On the contrary, it is very likely that an 8-year-old child may understand that the reason for their dental pain is a cavity in the tooth, and that the best way to treat the infection a filling to be placed in the tooth. However, the 8-year-old child may not be able to understand that failing to treat the tooth may lead to worsening infection, pain, and necrosis of the tooth now requiring pulp treatment or extraction. Therefore, the onus is on the dentist to discuss the treatment in detail with the child patient and his or her parents, and to use clinical judgement to decide the ability of the patient to given complete informed consent. If the dentist has reason to conclude that any of the aspects of informed consent are not met by the patient alone, then he or she has the responsibility to shift the informed consent decision to the patient’s legal guardian(s). However, the dentist also must be aware that while there is no distinct age limit to consent for dental treatment, minors in Ontario under the age of 18 cannot enter into a legally binding contract. In the dental practice, this means that the payment arrangement for any treatment rendered in the dental office cannot be enforced legally if this agreement has been made by a minor. 13 For example, a 17-year-old patient may give informed consent without his or her parent for the extraction of four wisdom teeth under IV procedural sedation in the dental office; however, if he or she refused to pay for the treatment afterwards, the dentist would not be able to enforce the payment agreement. Therefore, it is prudent that prior to providing any dental treatment, especially that is higher risk or costlier, the dentist takes the appropriate actions to discuss payment options with the parent/guardian of the minor during the informed consent discussion.

Challenges with Informed Consent and the Family
One of the more sensitive challenges faced by dentists treating paediatric patients in today’s world can be whether the adult who accompanies the patient does in fact have the legal right to give informed consent on behalf of the patient in a treatment discussion. It is not uncommon for an incapable minor patient to be accompanied to a dental appointment by a grandparent, aunt/uncle, or even a step-parent. This begs the question, should the dentist proceed with treatment in situations where the child is accompanied by someone other than the parent or legal guardian? Another situation that is not uncommon in today’s world is an incapable minor with divorced or separated parents presenting with a single parent to a dental appointment. In this case, what is the responsibility of the dentist in obtaining proper informed consent? According to risk management experts from the Professional Liability Program, an RCDSO program designed to provide risk management advice and malpractice protection for practicing dentists in Ontario, it is critical that the treating dentist understand the custody arrangement of any incapable minor prior to obtaining informed consent. 14 In situations of separation or divorce, the dentist is advised to ask both parents to provide a written statement outlining if one or both parents have custodial rights to make decisions on behalf of the child’s best interest, as well as any legal limitations that may have been agreed upon in court. 14 In addition, the dentist is advised to take the initiative to contact both parents separately to determine their preferred way to discuss patient information, progress, and treatment planning should one parent not be available at the appointment and be consistent with the nature of these discussions on an ongoing basis. 14 In situations where someone other than the biological parent has custody of a minor patient, the question of providing informed consent on behalf of the patient may be more complicated. Therefore, it is in the best interest of the patient that the dentist has set protocols to follow to obtain the correct legal documentation required to prove legal guardianship and custodial rights of the patient prior to providing any form of dental treatment. 14 When maneuvering these delicate situations, it may be best to incorporate the discussion regarding legal custody and guardianship of the minor patient as a standard protocol of a new patient exam, as part of taking an accurate medical and social history of the patient.

In Summary
In an any paediatric dental practice, it is more common than not that the patient presenting to the office is doing so on the decision of the parent or legal guardian. However, it is important that the practicing dentist acknowledge and respect the decision-making ability of the child patient, within the guidelines set by the RCDSO. If at all possible, it is beneficial for the patient, parent/guardian, and the treating dentist if everyone is on the same team during a treatment. In paediatric dentistry, this requires excellent communication skills on behalf of the dentist to discuss the proposed treatment in a way that is accessible to both patients and parents, with the goal of making both parties active members of treatment decisions whenever possible. OH

Oral Health welcomes this original article.

References

Canadian Medical Protective Association. 1996. Consent: A Guide for Canadian Physicians. 3rd Edition.

Flory J and Emanuel E. 2004. Interventions to improve research participants’ understanding in informed consent for research: a systematic review. The Journal of the American Medical Association. 292: 1593-601.

About the Author
Dr. Erin Goertzen is a graduate of the University of Toronto, Faculty of Dentistry, and is currently a dental resident in the Department of Dentistry at the Hospital for Sick Children in Toronto, Ontario.